Name of Patient: H Age/Sex: 2 y.o, F Ward: Sta.

Rosa Bed #: 2 Chief Complaint: swelling at the operation site

Diagnosis: Post VP Shunting for Hydrocephalus Physician: Dr. Davis

Date Cues Nee Nursing Diagnosis Patient Nursing Implemen Evaluation

/ d Outcome Interventions tation
Time
S S: Risk for infection related to At the end of 1. Establish Rapport 1 Sep 9, 2020
E “dili ko insufficient knowledge on the 8 hour R: To gain cooperation with the patient @ 2 PM
P kabalo mag S managing wound care at the shift, the 2. Note and report characteristics of 5 “Goals are
dressing” A incision site patient will drainage on dressings. completely
9 as F be able to R: Provides data indicating presence or met”
, verbalized E have no potential for infection which affects The patient
2 by the T Rationale: signs of shunt function. was able to
0 mother Y Appropriate surgical wound infections by 3. Monitor temperature every four (4) 3 show
2 O: / and incision management in demonstratin hours. negative
0 Dirty P the post-operative time g proper R: Elevation of temperature indicates signs of
wound R period is imperative to wound care infection. infections as
@ dressing O prevent complications, management 4. Teach about signs and symptoms 7 evidenced by
Foul odor T including surgical site with the help of infection site normal
8 coming E infection and wound of a R: Promotes early detection of infection temperature
A from the C dehiscence. Preventing significant 5. Follow principles of asepsis when 4 of 36.8℃ and
M wound T incisional infection by other performing procedures such as was able to
Presence I appropriate cleansing, skin dressing changes. demonstrate
of pus O care, and moisture R: Prevents transmission of proper
Elevated N management is a requisite microorganisms to shunt site. aseptic
temperatur part of the post-operative 6. Teach the watcher about wound 8 technique
e of 38.2℃ plan of care. care and dressing change, with the help
Irritability emphasize the importance of good of a
Tendernes handwashing techniques. significant
s at the R: Provides clean, sterile dressings other
wound site when soiled or wet.
7. Perform tepid sponge both 2
Reference:
National Institute for Health
and Clinical Excellence
(NICE). Surgical site
infection: evidence update
June 2013.
www.nice.org.uk/guidance/cg
74/evidence/ evidence-
update-241969645.
R: To reduce body temperature
8. Encourage intake of protein-rich 9
and calorie-rich foods
R: Proper nutrition place a part in
supporting the immune systems’
responsiveness.
9. Administer antibiotic therapy as 10
prescribed.
R: Antibiotics are effective against the
organism infecting the shunt.
10. Elevate the head of the bed 6
gradually about 15-45 degrees as
indicated. Maintain the client’s head
in neutral position.
R: This promotes CSF drainage and
breathing.

Reference: Martin, B. (2019). Retrieved

from https://nurseslabs.com/5- Jennifer D.
hydrocephalus-nursing-care-plans/5/ Condiman
St. N
References:
National Institute for Health and Clinical Excellence (NICE). Surgical site infection: evidence update June 2013.
www.nice.org.uk/guidance/cg74/evidence/ evidence-update-241969645.
Martin, B. (2019). Retrieved from https://nurseslabs.com/5-hydrocephalus-nursing-care-plans/5/
NANDA International, Inc. Nursing Diagnoses: Definitions & Classification 2015–2017, Tenth Edition. Edited by T. Heather Herdman
and Shigemi Kamitsuru. © 2014 NANDA International, Inc. Published 2014 by John Wiley & Sons, Ltd. Companion website:
www.wiley.com/go/nursingdiagnoses

Clustering of Cues
Activity/ Rest
Elevated temperature of 38.2℃
Health Promotion
“dili ko kabalo mag dressing” as
verbalized by the mother
Dirty wound dressing
Elimination and Exchange Self-Perception/ Self Concept
Presence of pus Irritability
Foul odor coming from the
wound
Tenderness at the wound site